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International Health Electives: Strengthening Graduate Medical Education

Sidney Coupet, DO, MPH

An international health elective (IHE) can be an important n 1997, the Institute of Medicine recognized the impor - component of the medical education and professional Itance of global health training for US by development of a . It provides essential global calling for more awareness of the impact of globalization. 1 health skills that are crucial in a globalized society. Grad - In addition, in 2003 the World Federation for Medical Edu - uate medical education has an opportunity to deliver cation advocated for a more globally mobile health care such skills to our health care workforce while addressing workforce and the creation of a global health practitioner, the pending workforce shortage and the uneven distri - or one who thinks globally and acts locally. 2 These practi - bution of primary care physicians across the United tioners would have an opportunity to learn about different States. Currently, there is a call for graduate medical edu - cultures, health systems, and public health challenges of cation programs to create more training sites and to low-resource countries around the world and apply that undergo reform that will help fill residency slots and knowledge to the way they practice medicine in the United train more primary care physicians. The author proposes States. With these calls for global health initiatives, global that graduate medical education programs incorporate health education for US physicians has received increased international health electives into their accredited resi - attention, including fieldwork that takes place internation - dency programs. This addition could potentially ally. These international rotations, referred to as interna - strengthen their programs while making them more tional health electives (IHEs), 3 have become popular among appealing to qualified candidates. US physicians-in-training because of the educational and J Am Osteopath Assoc . 2012;112(12):800-804 personal advantages they provide, including the expansion of clinical knowledge, the improvement of physical exam - ination skills, and the opportunity to practice medicine in underserved and multicultural regions. 4 Both osteopathic and allopathic medical schools a r o u nd the country have well-established IHE programs, 5,6 and US graduates are seeking out residency programs that also have established IHEs. 4,7,8 I recommend that graduate medical education (GME) programs that are looking to increase their number of residency slots 9 strongly consider establishing an IHE program. By offering inter - national clinical experience, GME programs could strengthen residents’ training and potentially increase the number of qualified applicants to their programs. Moreover, improving global health education for residents would help meet the global health care needs of our evolving society. 2 In the present article, I discuss the benefits and potential challenges in establishing IHEs and make the case for incorporating IHEs into GME programs. Financial Disclosures: None reported. Address correspondence to Sidney Coupet, DO, MPH, Robert Wood The Importance of an IHE Johnson Foundation Clinical Scholar Program, Department of Internal Med - icine, University of Michigan, 2800 Plymouth Rd, Building G016, Ann Arbor, An IHE provides immediate and long-term educational 3 MI 48109-0600. and personal growth for physicians. For example, E-mail: [email protected] Sawatsky et al 3 reported that physicians who participate

Submitted July 1, 2012; revision received September 6, 2012; accepted Sep - in an IHE will rely more on patient history and physical tember 13, 2012. examination findings than on diagnostic testing when

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caring for patients. Other studies 10,11 have shown that IHEs research and exposure to different health care delivery sys - provide a cultural aspect to education and instill cultural tems. Additional studies are also needed to better differ - humility in physicians, a trait that is important to meeting entiate those benefits from lower resource settings. the health care needs of our increasingly diverse society. For example, a study by Campbell et al 11 showed that sur - Osteopathic GME Programs gical residents acquired improved understanding of the Graduate medical education in the United States is under - global burden of surgical diseases, global public health going a major transformation. In October 2012, the AOA, issues, and cultural sensitivity after exposure to cross-cul - the American Association of Colleges of Osteopathic tural communication. The long-term impacts of an IHE Medicine, and the Accreditation Council for Graduate are likely to benefit our health care system. For instance, Medical Education (ACGME) announced plans to discuss Miller et al 12 found that physicians who participated in an a unified accreditation system. 19 With this merger, the IHE program were more likely to choose primary care as ACGME would be the single accreditation system for all their specialty or to choose to practice in underserved com - US GME programs. However, the ACGME standards munities in the United States. 12 would recognize distinctly osteopathic competencies in International health electives also train physicians to programs currently accredited by the AOA. 20 Therefore, deal with health care in the 21st century—a more globalized the osteopathic medical profession will still be in the crit - society. 2 Moreover, in light of recent terrorist attacks and ical position of determining the future of our osteopathic natural disasters, our society is facing new medical issues medical health care workforce. The osteopathic medical and disease burdens that were once known to be problems profession has faced this challenge in recent years; the of only other nations. 13,14 For example, chronic respiratory number of osteopathic physicians in osteopathic GME diseases were associated with posttraumatic stress syn - programs increased by 50% from the 2006-2007 to the drome among rescuers and recovery workers after the 2010-2011 academic years—certainly nowhere near the World Trade Center terrorist attack on September 11, 2011, 15 number needed to address the pending physician and there was a Norovirus outbreak immediately after shortage in this country. 21 There has been a call for more Hurricane Katrina in 2005. 16 Whereas these disease burdens strategies to increase the number of osteopathic GME were unexpected and rare in the United States, they are programs to meet the growing number of graduates from more common in developing and conflict-prone nations colleges of osteopathic medicine. 9 As osteopathic GME around the world. An IHE can provide early exposure to programs look to increase their number of positions, they these disease burdens, which would be of great value to should also consider their ability to attract recent grad - our future physicians. uates. International health electives are one way in which Graduating medical students are aware of the osteopathic GME programs can attract graduates and demands of global health care and are now seeking GME ensure positions are filled. programs with established IHEs. 4 In 2009, a survey of 794 In light of the increased interest of osteopathic medical surgical residents in the United States revealed that 92% students in IHEs, colleges of osteopathic medicine are of survey respondents were interested in an IHE. 17 Addi - already attempting to meet these demands by creating tional studies 4,7,8 have suggested that graduates from US student-level international experiences either independently allopathic medical schools are using IHE as a criterion for or by means of nongovernmental organizations such as selecting their residency programs. Although we have no Doctors United For Haiti, foundations, and other types of current data on the selection criteria of graduates from medical organizations like DOCARE International. 5 osteopathic medical schools, it is likely that they too may Although there have been recommendations to osteopathic be using IHE as a deciding factor for their residency selec - GME programs on how to establish an IHE, 22 little is known tion process. about whether IHE programs are common among osteo - Although some of the personal and professional ben - pathic GME programs and whether there are challenges efits of an IHE may be acquired through rotations in and problems that are unique to osteopathic IHEs. Regard - resource-poor settings in the United States, 18 more studies less of whether one believes in the future primary care will need to be conducted to differentiate the most cost- physician shortage or the unequal geographic distribution effective means of obtaining these valuable skills. An IHE of available health care in the United States, 23 one would is unique, however, in that it provides hands-on educational certainly agree that the osteopathic medical profession is experiences for residents to learn about the global burden in a key position to address these issues, and that influ - of diseases. 11 In addition, although the present article mostly encing and training our future physicians in global health refers to the impact of IHEs that involve low-income coun - is paramount. Similar to the influences and benefits that tries, there may also be benefits to conducting IHEs in high- an IHE can have for medical students, 24 an IHE in residency income countries, such as opportunities for collaborative programs may potentially have a greater impact.

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Addressing the Concerns and Challenges of an IHE Common concerns of GME program staff in establishing Change in funding patterns for GME an IHE include lack of supervision for trainees, lack of Establishment of a GME- or residency-specific IHE guidelines and standardizations, and lack of support from council or committee stakeholders. 20 The most often cited obstacle is the IHE’s Commitment by leading resident and physician expense. 25 Institutional funding sources for residents who organizations participate in rotations abroad have been scarce and, as a Policy statement by the American Osteopathic result, institutions are requesting changes to their funding Association and the Accreditation Council for patterns (eg, becoming a Federally Qualified Health Center) Graduate Medical Education and applying for state grants and creating separate accounts Individual hospital commitment 25 for IHEs. With current funding patterns (eg, Centers for Development of a nationally funded global health Medicare and Medicaid payments), some institutions may service corps be concerned about a loss of income associated with having residents away from the base institution. In addition, despite pressure from policymakers on GME programs Figure . Strategies to increase international health electives to train more primary care physicians, lack of funding has (IHEs). Adopted from Grudzen et al. 24 Abbreviation: GME, been found to hinder any appropriate reform. 26 These graduate medical education . issues further hinder the prospects of successfully incor - porating IHEs in GME programs. Efforts have already been made to address these poten - tial obstacles and help GME programs establish more IHEs time for physicians-in-training to participate in an IHE. (Figure ). Although not exclusive to residency programs, Compared with medical students, residents have acquired the AOA has created guidelines regarding international some clinical context and have a greater ability to contribute clinical clerkship and cultural competency for students. 22 to the delivery of care to host nations in which an IHE is Strategies such as obtaining Federal Qualified Health established. 4 Therefore, an IHE that involves residents with Center status for US community teaching health care cen - the ability to treat patients would be useful to a developing ters, increasing residency slots, and obtaining other grants nation that is facing health care workforce shortages. These have been shown to help some residency programs remain considerations are especially important as there are already financially viable. 26 We suspect that these strategies can concerns about volunteers who are inadequately prepared, also create funding opportunities for IHEs. Moreover, the are a drain to a team, and are causing limitations to care US President’s Emergency Plan for AIDS Relief, or PEPFAR, and services delivered in these settings. 30 has been advocating for an exclusive global health corps with financial incentives for physicians. 27 This corps may IHE Progress also serve as a potential funding solution if implemented. Both osteopathic and allopathic medical schools have well- Although we have started recognizing some funding strate - established IHEs. 24 One of the greatest milestones of medical gies for GME, 25,27 more studies are needed to demonstrate school IHEs is their ability to influence young physicians true cost benefits for specific strategies in different types to go into primary care professions, thereby meeting an of programs. important need of the US health care system. 31,32 The resi - There have also been concerns about the ethical prac - dency programs that foster global health interest through tices and the impacts of IHEs on host nations. 28,29 Dharamsi IHEs have also shown success in a number of areas. 3,4,10,12,33 et al 28 found that appropriate preparation and reflection Yale University’s Internal Medicine Residency program for residents before participating in an IHE can encourage started its first IHE site in Haiti in 1981. 34 Their program residents to practice ethical and sustainable practices while has been in existence for more than 3 decades and provides in the host nation. In response, the AOA Bureau on Inter - 4- to 6-week rotations for second- and third-year internal national Osteopathic Medical Education and Affairs put medicine residents. A retrospective survey study 10 showed together a set of guidelines for IHEs, including a strong that participants and nonparticipants of an IHE were recommendation that osteopathic GME programs establish equally likely to change their career plans. However, the a code of conduct to ensure residents “do no harm” while 2 groups did differ when it came to the type of career practicing in resource-poor settings. 22 The set of guidelines change; those who participated in an IHE were 56% more was approved in 2011 by the AOA House of Delegates, likely to change their career choice from a subspecialty to asserting that health has to be the primary purpose of any general internal medicine compared with 31% of nonpar - medical mission. ticipants. 10 In addition, participants were more likely to Drain et al 4 have suggested that residency is the best practice in underserved settings and care for the poor. 10

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Participants of the Mayo International Health Program 8. Garbern SC. Medical relief trips...what’s missing? exploring ethical issues and the physician-patient relationship. Einstein J Biol Med. 2 009;25(1):38-40. http: demonstrated heightened cultural awareness, were exposed //www.einstein.yu.edu/uploadedFiles/EJBM/page38_page40.pdf. Accessed November to diseases they might not have otherwise encountered, 16, 2012. had increased awareness of cost, and gained improved 9. DeRosier A, Lischka TA. Osteopathic graduate medical education 2012. J Am history and physical examination skills. 3 A survey by Miller Osteopath Assoc. 2012;112(4):196-203. http://www.jaoa.org/content/112/4/196 .full.pdf+html. Accessed June 22, 2012. et al 12 on the Duke University Medicine Residency Inter - 10. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Pro - national Health Program found that many new graduates gram: the fifteen-year experience with Yale University’s Internal Medicine Residency from medical schools are seeking programs with estab - Program. Am J Trop Med Hyg. 1999;61(6):1019-1023. http://www.ajtmh.org lished IHEs and that Duke University’s IHE is beneficial /content/61/6/1019.full.pdf+html. Accessed June 22, 2012. to its residency program. Despite these positive institutional 11. Campbell A, Sullivan M, Sherman R, Magee WP. The medical mission and experiences, IHEs do not exist in all graduate training pro - modern cultural competency training. J Am Coll Surg . 2011;212(1):124-129. grams, and currently it is unclear how many exist among 12. Miller WC, Corey GR, Lallinger GJ, Durack DT. International health and internal medicine residency training: the Duke University experience. Am J Med. 1995;99(3): osteopathic GME programs. 291-297. 13. Galea S, Vlahov D, Resnick H, et al. Trends of probable post-traumatic stress Conclusion disorder in City after the September 11 terrorist attacks. Am J Epidemiol. 2003;158(6):514-524. http://aje.oxfordjournals.org/content/158/6/514.full.pdf+html. International health electives are an important component Accessed June 22, 2012. of global health education. International experience is 14. Greenough PG, Lappi MD, Hsu EB, et al. Burden of disease and health status important to osteopathic medical school graduates, who among Hurricane Katrina-displaced persons in shelters: a population-based cluster are seeking GME programs that offer IHEs. As GME pro - sample. Ann Emerg Med. 2008;51(4):426-432. http://www.jhsph.edu/research /centers-and-institutes/center-for-refugee-and-disaster-response/publications_tools grams look to create new residency positions in response /publications/2008/Burden_of_Disease_and_Health_Status_Among_Hurricane to physician shortages and unequal distribution of primary _Katrina.pdf. Accessed June 22, 2012. care services, I propose that GME programs consider 15. What we know about the health effects of 9/11. The City of New York Web offering safe and organized IHEs to attract qualified appli - site. http://www.nyc.gov/html/doh/wtc/html/know/mental.shtml. Accessed November cants. More importantly, the implementation of IHEs can 16, 2012. prepare our physicians for the demands of globalization 16. Watkins RR. Gastrointestinal infections in the setting of natural disasters. Curr Infect Dis Rep. 2012;14(1):47-52 and improve the quality of care in the United States and 17. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a abroad. national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208(2):304-312. Acknowledgments 18. Weissman JS, Campbell EG, Gokhale M, Blumenthal D. Residents’ preferences I am grateful for the editorial help of Stephen C. Shannon, DO, and preparation for caring for underserved populations. J Urban Health. 2001;78(3): 535-549. and Tyler Cymet, DO, president and vice president, respectively, 19. MDs and DOs moving toward a single, unified accreditation system for graduate of the American Association of Colleges of Osteopathic Medicine. medical education [news release]. Chicago, IL: American Osteopathic Association; October 24, 2012. http://www.osteopathic.org/inside-aoa/news-and References -publications/media-center/2012-news-releases/Pages/10-24-MDs-and-DOs-moving 1. Macfarlane SB, Jacobs M, Kaaya EE. In the name of global health: trends in -toward-single-accreditation-system-for-graduate-medical-education.aspx. Accessed academic institutions. J Public Health Policy. 2008;29(4):383-401. November 6, 2012. 2. McKimm J, McLean M. Developing a global health practitioner: time to act? 20. Buser BR. A single, unified graduate medical education accreditation system. Med Teach . 2011;33(8):626-631. J Am Osteopath Assoc. 2012;112(12);772-773. 3. Sawatsky AP, Rosenman DJ, Merry SP, McDonald FS. Eight years of the Mayo 21. Shannon SC. The problem with graduate medical education [editorial]. J Am International Health Program: what an international elective adds to resident Osteopath Assoc. 2012;112(4):166-167. http://www.jaoa.org/content/112/4/166.long. education. Mayo Clin Proc . 2010;85(8):734-741. http://www.ncbi.nlm.nih.gov/pmc Accessed June 22, 2012 /articles/PMC2912735/?tool=pubmed. Accessed June 22, 2012. 22. American Osteopathic Association Bureau on International Osteopathic Medical 4. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global health training and Education and Affairs. White Paper on Guidelines for International Electives and international clinical rotations during residency: current status, needs, and oppor - Cultural Competencies for Osteopathic Physicians-in-Training . Chicago, IL: American tunities. 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26. Lesko S, Fitch W, Pauwels J. Ten-year trends in the financing of family medicine review. Fam Med . 2010;43(1):21-28. http://www.stfm.org/fmhub/fm2011/January training programs: considerations for planning and policy. Fam Med. 2011;43(8):543- /Jessica21.pdf. Accessed June 22, 2012. 550. http://www.stfm.org/fmhub/fm2011/September/Sarah543.pdf. Accessed June 31. Rosenblatt RA, Andrilla CH. The impact of U.S. medical students’ debt on their 22, 2012. choice of primary care careers: an analysis of data from the 2002 medical school 27. Institute of Medicine. Healers Abroad: Americans Responding to the Human graduation questionnaire. Acad Med. 2005;80(9):815-819. Resource Crisis in HIV/AIDS . Washington, DC: National Academies Press; 2005. 32. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global 28. Dharamsi S, Osei-Twum J-A, Whiteman M. Socially responsible approaches to health in medical education: a call for more training and opportunities. Acad international electives and global health outreach. Med Educ. 2011;45(5):530- Med. 2007;82(3):226-230. 531. 33. Chiller TM, De Mieri P, Cohen I. International health training: the Tulane expe - 29. Birch M, Miller S. Humanitarian assistance: standards, skills, training, and expe - rience. Infect Dis Clin North Am. 1995;9(2):439-443. rience. BMJ. 2005;330(7501):1199-1201. http://www.ncbi.nlm.nih.gov/pmc/articles 4. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Pro - /PMC558022/pdf/bmj33001199.pdf. Accessed June 22, 2012. 3 gram: the fifteen-year experience with Yale University’s Internal Medicine Residency 30. Jeffrey J, Dumont RA, Kim GY, Kuo T. Effects of international health electives Program. Am J Trop Med Hyg. 1999;61(6):1019-1023. on medical student learning and career choice: results of a systematic literature

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